Director's Report to the National Advisory Council on Drug Abuse - September, 2002

Research Findings - Services Research

A Synthesis of Welfare Reform Policy and Its Impact on Substance Users

The purpose of this study was to provide an overview of welfare reform and its impact on the substance-abusing recipient. Factors relevant to transitioning welfare recipients into the workplace, such as transportation and childcare, have special ramifications for the drug-using population. These individuals require treatment for their addictions in order to become employable. The issue of concern is that recipients may be deterred from seeking benefits by various provisions of welfare reform legislation and turn instead to other sources (including illicit activities) for sustenance. Welfare caseloads have been dropping over the past two years. However, the number of substance abusers continues to rise. Montoya, I.D. and Atkinson, J.S. Am J Drug Alcohol Abuse, 28(1), pp. 133-146, 2002.

Benefit-Cost Analysis of Addiction Treatment: Methodological Guidelines and Empirical Application Using the DATCAP and ASI

This study provides detailed methodological guidelines for using the Drug Abuse Treatment Cost Analysis Program (DATCAP) and Addiction Severity Index (ASI) in a benefit-cost analysis of addiction treatment. A representative benefit-cost analysis of three outpatient programs was conducted to demonstrate the feasibility and value of the methodological guidelines. Procedures are outlined for using resource use and cost data collected with the DATCAP. Techniques are described for converting outcome measures from the ASI to economic (dollar) benefits of treatment. Finally, principles are advanced for conducting a benefit-cost analysis and a sensitivity analysis of the estimates. DATCAP was administered at three outpatient drug-free programs in Philadelphia, PA, for 2 consecutive fiscal years (1996 and 1997). The ASI was administered to a sample of 178 treatment clients at treatment entry and at 7-months post-admission. The DATCAP and ASI appear to have significant potential for contributing to an economic evaluation of addiction treatment. The benefit-cost analysis and subsequent sensitivity analysis all showed that total economic benefit was greater than total economic cost at the three outpatient programs, but this representative application is meant to stimulate future economic research rather than justifying treatment per se. This study used previously validated, research-proven instruments and methods to perform a practical benefit-cost analysis of real-world treatment programs. The study demonstrates one way to combine economic and clinical data and offers a methodological foundation for future economic evaluations of addiction treatment. French, M.T., Salome, H.J., Sindelar, J.L., and Mclellan, A.T. Health Services Research, 37(2), pp. 433-455, 2002.

Integration and its Discontents: Substance Abuse Treatment in the Oregon Health Plan

In this article the authors examined the impact managed care had on access to integrated substance abuse treatment and physical care services for Medicaid clients. Managed care practices of 7 health plans serving Medicaid clients in the state of Oregon were explored between 1996 and 1998. Results indicated the original vision of integrating substance abuse treatment services with physical care for enrollees evolved into a multi-layered, carved-out approach. Factors working against integration included changes in the administration and management of the chemical dependency benefit, financial losses by health plans, and lack of training and incentives for physicians to refer clients to substance abuse treatment. Laws, K.E. and McFarland, B.H. Health Aff, 21(4), pp. 284-289, August 2002.

The Impact of Withdrawals By Medicaid Managed Care Plans on Behavioral Health Services

In 1991, there were 9.5 percent of Medicaid enrollees in some form of managed care, but by 1999, this stood at 55.6 percent with 17.8 million enrollees. The authors examined the impact when managed care plans decide to abandon the state Medicaid market. There is concern for those mental health and substance abuse patients who would have to adjust to a new approach to their care management, and continuity of care may also be threatened. Three case studies of Missouri's integrated, Oregon's carve out, and New Jersey's fee-for-service programs are discussed. These cases suggest that carve-outs and fee-for-service arrangements offer some protection against disruption to treatment when a managed care plan exits the Medicaid market. Huskamp, H.A., Garnick, D.W., Hanson, K.W., and Horgan, C. Psychiatric Services, 52(5), pp. 600-602, 2001.

Measuring Perceptions of Innovation Adoption in Drug Abuse Prevention

A 17-item scale was administered to 107 Safe and Drug Free Schools (SDFS) coordinators in 12 states as a part of a larger investigation examining the diffusion of a federal drug prevention policy. The scale was based on theory, previously validated measures, expert review, and pre-testing with SDFS coordinators. Factor analysis revealed three underlying constructs representing relative advantage/compatibility, complexity and observability. Each construct was correlated with a district's adoption of the drug prevention policy. The relative advantage/compatibility construct was especially useful in assessing policy adoption. This scale has the potential to be easily adapted for use in understanding the adoption of other health education interventions. Measuring Perceptions of Innovation Adoption: The Diffusion of a Federal Drug Prevention Policy. Pankratz, M., Hallfors, D., and Cho, H. Health Education Research, 17(3), pp. 315-326, 2002.

Cost-benefit and cost-effectiveness analyses of two, brief, universal family-focused interventions were conducted to assess their value for preventing alcohol use disorders. The interventions were the Iowa Strengthening Families Program (ISFP), a seven-session intervention with parents and students together, and Preparing for the Drug Free Years (PDFY), a five-session intervention focusing primarily on parents. Both interventions included instruction on parenting skills designed to support family-related protective factors and reduce family-related risk factors for substance use. Thirty-three rural schools in 19 contiguous counties were blocked on school size and randomized to ISFP, PDFY, or minimal contact control conditions. During in-home assessments, students provided self-reported data on alcohol use from which age of alcohol-use onset was calculated. Analysis involved assumptions based on expected alcohol disorder rates given alcohol initiation data in the three conditions. ISFP demonstrated a cost-effectiveness of $12,459 per case prevented, a benefit-cost ratio of $9.60 per $1 invested, and a net benefit of $5,923 per family. PDFY demonstrated a cost effectiveness of $20,439 per case prevented, a benefit-cost ratio of $5.85 per $1 invested, and a net benefit of $2,697 per family. Universal family skills training interventions have the potential to delay the onset of alcohol use and reduce societal costs of alcohol disorders. Spoth, R.L., Guyll, M., and Day, S.X. Universal Family-Focused Interventions in Alcohol-Use Disorder Prevention: Cost Effectiveness and Cost-Benefit Analyses of Two Interventions. Journal of Studies on Alcohol, 63, pp. 219-228, 2002.

Factors Associated with Adolescent Alcohol Treatment Service Use

The authors used data from the National Household Survey on Drug Abuse to examine factors associated with adolescents' use of alcohol treatment services. The majority of adolescents reporting problems related to alcohol use did not receive treatment. Among those receiving treatment, white adolescents were more likely to do so than non-white adolescents. Problems in home, school, or other settings, or associated drug use and poor health were more predictive of receiving alcohol treatment. The authors call for improved service delivery to meet the needs of adolescents with alcohol problems, as many are not receiving treatment. Wu, P., Hoven, C.W., Tiet, Q., Kovalenko, P., and Wicks, J. Factors Associated with Adolescent Utilization of Alcohol Treatment Services. American Journal of Drug and Alcohol Abuse, 28, pp. 353-369, 2002.

The authors examined the influence of a centralized intake system on client outcomes of alcohol and drug use, and legal and psychiatric problems as measured by the Addiction Severity Index. Data was collected at baseline, six month, and twelve month intervals following intake and compared for clients experiencing two different models of centralized intake. Centralized intake clients were more likely than provider intake clients to have legal problems, and those legal problems became fewer over time. Clients from in-jail intake, including pretreatment services and accompanied placement, showed greater initial and lower subsequent prevalence of drug, psychiatric, and legal problems than the clients of freestanding centralized intake. For all clients, higher psychiatric composite scores were powerful predictors of problems in alcohol, drug, medical, and legal areas. McFarland, B.H. and McCamant L. J of Psychoactive Drugs, 34(1), pp. 75-86, March 2002.